Minimal comfort feeding in palliative care in the light of the Anscombean-Thomistic virtue ethics theory of action.

The ethical terrain surrounding feeding at the end-of-life is emotionally charged and complex. In the literature, the recently introduced notion of "minimal comfort feeding" (MCF), defined as deliberate limitation of feeding or hydration, given only in response to visible signs of hunger or thirst, for a patient with a longer prognosis, has been proposed as a comfort measure at the end of life and as an alternative to voluntarily stopping eating and drinking (VSED) in advance care planning. However, the same term may be applied to two morally distinct acts: 1) providing comfort in the context of active dying, and 2) a hastening death. In this paper, we argue for conceptual clarity around these two practices and their ethical valence, drawing on an Anscombean-Thomistic virtue ethics framework that deals with moral evaluation of human action and the doctrine of double effect. We present two clinical cases highlighting each of these ethical scenarios. Through the cases, we show how intentionality and some circumstances such as timing critically shape the morality of the act. We propose a new nomenclature with the aim of fostering ethical clarity of the morally distinct acts: "proportionate comfort feeding" (PCF) for MCF where nutrition and hydration is provided for comfort with the understanding that it may hasten death but is its foreseen, unintended outcome, and "minimal feeding to hasten death" (MFHD) for cases where MCF is chosen with the specific intention to hasten death.